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an action of the bowels. One of my patients-a nurse in the hospital, who was suffering from an acute attack of the disease contracted in the hospital, and occurring at the same time as the case of paratyphoid disease I have already recorded-had on several occasions hæmorrhage of the most alarming description; and it is noteworthy that a larger hæmorrhage always coincided with constipation, more or less marked, while slighter attacks, which seemed to influence her condition but little, occurred when the bowels were relaxed. The treatment of this condition must, of course, vary with one's conception of its cause. When I have believed it to be due to a general intestinal catarrh, I have found it influenced by the use of bismuth, which seems to have no effect whatever when it is due to hyperæmia of Peyer's patches, and still less when it is due to an ulcerated process extending almost to the peritoneal wall of the bowel. In these cases the first essential is to keep the bowels in a state of absolute rest, and for this purpose opium is our sheet anchor. I know of no other drugs which give one any confidence in dealing with this condition, and the only other procedure which I employ is the application of an ice coil to the abdominal surface. If the patient seems to be sinking from the amount of blood lost, I administer strychnine subcutaneously, and order large enemas of a saline solution. From lead, ergot, and other hæmorrhatic drugs I have derived no benefit.
DEATH FROM PERFORATION IN TYPHOID.
The experience in London hospitals has shown that more than 3 per cent. of all cases of typhoid die from this cause, and of all the deaths that occur from the disease, more than 25 per cent. are occasioned by this terrible accident. It was held formerly that no patient ever recovered when perforation occurred, and there are many still strongly convinced that such is the case unless surgical interference be invited.
Personally, I have had but little experience of surgery in this condition, and it is one of the particular reasons for my reading this paper that I may get the experience of those who
have been more fortunate, or perhaps more courageous than myself in obtaining the aid of surgery to avert death. I cannot, however, accede to the proposition that death must occur, for I have had several cases in which there seemed no moral doubt that perforation had occurred, and in which recovery took place without operation. Twenty years ago I saw in consultation a young man of twenty who, whilst apparently doing well after a severe attack of typhoid, became suddenly collapsed, his abdomen became greatly distended, the liver dulness was lost, and no movement of the abdomen (which was rigid) took place during respiration ; his pulse became rapid and feeble and hard; the temperature fell in the course of a few hours to 97 degrees, and became subnormal; his face presented a Hippocratic expression, and no doubt was entertained that he was within measurable distance of an early death. His friends suggested further consultation, and we had the benefit of the opinion of the late Dr. Heslop, who concurred with the diagnosis of perforation, and joined us in a fatal prognosis. Opium was given—not, however, with the idea of benefiting the patient—and food was almost stopped. Very gradually the distension subsided; the pulse improved in quality, while diminishing in frequency; and gradually all bad symptoms disappeared, and the patient made a good recovery.
Last year I had in the hospital a patient who also, I was satisfied, had perforation, and whose case I should like to read in some detail. He was a strong, healthy lad, aged sixteen, who six weeks before admission began to feel ill and suffered froin diarrhoea for a few days, with some pain in the abdomen, whilst at the same time he complained of slight cough. A doctor who was summoned diagnosed inflammation of the bowels, and after a few days' treatment he began to improve a little, but never got rid of the feeling of illness. He kept his bed all the time. Another doctor, having been called in about a week before admission, diagnosed enteric. At this time he had no diarrhoea, but the one daily action of the bowels was copious and fluid and offensive. On admission, he was found to be very collapsed. Temperature,
103 degrees; pulse, 120; respiration, 28. There was extreme general tenderness on pressure over the abdomen, with diminished liver dulness and resonance in the flanks. The knees were drawn up; he was very restless, with muttering delirium. His face was drawn and anxious; there were sordes on the teeth, and his tongue was dry and cracked. The abdomen was so rigid that the spleen could not be palpated. No doubt was entertained that he had been suffering from typhoid, and that perforation had occurred; but, after a consultation, it was decided that he was too ill to bear an operation. The next day he was thought to be steadily sinking; the pulse was quicker and wiry, but not irregular, and the temperature ranged from 98 to 100 degrees. The abdomen was hard and rigid, very tender, especially on the left of the umbilicus, but pain was induced on pressure anywhere. That evening he was very restless, and a copious motion followed the adminstration of an enema. Next day he remained in much the same condition—a state of profound asthenia, in which he had lost command of his sphincters. He complained of abdominal pain, was very restless, and had to be watched constantly; pulse was rapid and dicrotic; face very anxious. On the following day he was about the same, restless and delirious, and attempted to get out of bed; the abdomen moved very little on respiration, but the rigidity of the abdominal wall was not quite so marked. On the following day he was no worse, except that his face was more pinched and a trifle more anxious; the abdomen was still distended, but not so much so as at the time of admission ; tongue dry and brown; pulse still rapid and wiry. On the following days it was noted that he was said to be in a state of increasing weakness and exhaustion. Then pulse began to get slower, and his abdomen became less distended, moved a little on respiration, and he seemed to be improving generally. Very slowly all bad symptoms disappeared, and he ultimately became convalescent, leaving the hospital ten weeks after admission for a sanatorium.
These two cases-in each of which I have no doubt perforation occurred—are at least proof that a certain number
of last year.
of cases will get well without operation, but they form a very small proportion of recoveries compared with the deaths that have occurred in my practice; and if Dr. Kean's statistics can be corroborated by the experience of others, I have very little doubt that his dictum " that all cases of perforation should have the benefit of operative interference ” should ultimately become an axiom of practice. It would be fortunate indeed if one could estimate the probability of the occurrence or non-occurrence of perforation in our
Unfortunately, so far as my experience goes, this is not possible, and some of the most distressing cases have to deal with are those which occur in cases in which we believe that convalescence or even complete cure has taken place. Such a case is that of a patient, aged thirty-eight, who was under my care in the General Hospital in February
He was a remarkably powerful and vigorous man, who had suffered from a moderately severe type of the disease. He gradually improved so far that in the seventh week he was said to be quite well, but his temperature still varied a little, though only on two occasions did it exceed the normal. In the eighth week, after his temperature had, with these two exceptions, been normal for twenty-two days, and his diet had been improved so far that he was taking a little fish and milk pudding, he was one day found with greatly distended abdomen, which was rigid and tender all over; his pulse ran up to 126, and his temperature to 101 degrees. His face was anxious and drawn, and he seemed to be greatly distressed. Perforation was diagnosed, and an operation was performed, which revealed very dark-red angry coils of intestine, with masses of fresh lymph tending to mat the coils together. A small pin-head perforation was discovered and stitched, probably at the lower end of the ileum. He seemed to be doing pretty well, but one week after the operation he sank and died. The autopsy revealed general peritonitis; the operation wound had held together, but another larger perforation, the size of a threepenny bit, was discovered. This came as a great shock and surprise to me, and emphasised the fact, which should never be forgotten, that no patient is
safe in typhoid until he is able to take ordinary diet with impunity ; but the result of operation emphasises also more emphatically what has always appeared to me to be an argument against operation, namely, that where one perforation has occurred, the conditions are probably favourable to further perforations in other places. These cases have all exhibited distension of the abdomen as a sign of perforation, but I have had several other cases in which perforation has occurred without any distension ; and it seems likely that the presence or absence of general distension must depend entirely upon the presence or absence of adhesive peritonitis about the seat of the puncture. To distension, therefore, as a sign of perforation, I should be less disposed to attach importance than to rigidity of the abdominal wall and to tenderness on pressure. However, in an article on this subject in the January number of the Annals of Surgery, Drs. Harte and Cooper state that in 271 cases which were operated on, it was noted that the perforation was single in 236, and multiple in 35. Though the percentage of death is still very high after perforation, namely, 75 per cent., it is lower than in the cases in which no operation is attempted; and I am disposed to think that it would be my duty where I believed perforation had occurred to recommend operation.